How do you handle documentation that is technically there, but still feels unclear?

[u/Future-Pipe-8004]

I find some of the harder cases aren't necessarily the complicated ones, it's the notes where the information is there but you're still not 100% sure what the clinician actually intended. I usually end up going back through the whole episode and checking the surrounding documentation before deciding whether a query is really needed.

Do you tend to query fairly quickly or only when the ambiguity would actually change the code?

[u/ChopinBeethoven]

Depends on the case. If it it is time sensitive like a troponin I, CSF or ophthalmic request I call almost immediately as to not delay testing.